Inclement Weather and Dialysis Patients

“There’s no harm in hoping for the best as long as you’re prepared for the worst.” —Stephen King

As kidney patients with shared New England roots growing up on the coast of Maine and in the neighborhoods of Boston, Massachusetts, our respect for nature's power was shaped by the elements of the sea, snow, ice, fog, gale force winds, and driving rain. This is a region whose heritage, character, and everyday life is punctuated by weather and where locals and families still weave tales of perseverance forged by “The Great Hurricane of 1938,” “The Great Blizzard of 1978,” and the “Great Ice Storm of 1998” into daily conversations as easily as wry observations about politicians or the curious idiosyncrasies and strange attire of tourists. Yankees are an independent and tough lot, but they are never cavalier or disrespectful toward the weather—because it can kill you.

Rarely have we read a more pertinent reminder of nature's power, and its consequences for vulnerable people, than “Inclement Weather and Risk of Missing Scheduled Hemodialysis Appointments among Patients with Kidney Failure,” published in this issue of CJASN.¹ The authors pursued a simple hypothesis that the risks of missed hemodialysis appointments are higher after inclement weather events, measured over a period of 7 days, compared with noninclement weather days. Their study is the first to consider associations with treatment visits across multiple types of weather hazards as opposed to a single event, like Hurricane Katrina. Instead, they examined, for the period of 2001–2019, the effect of rainfall, snowfall, snow depth, wind advisories, and tropical storms and hurricanes across 27 New England counties using 60,135 deidentified health records of dialysis patients treated at 99 Fresenius Kidney Care clinics. The study population's total visits were 16,612,373 and missed appointments totaled 454,932. Missed appointments were defined as unexcused events when patients failed to show and excluded misses because of hospitalizations or prearranged travel. Weather history came from the US Department of Commerce's National Oceanographic and Atmospheric Administration and National Weather Service. County-specific weather exposures were assigned to dialysis clinic ZIP codes as proxy for a residence.

The results supported the hypothesis. Inclement weather days are a significant interference to scheduled dialysis treatments compared with days without inclement weather. All types of inclement weather affected treatments on the first day of occurrence, and the lag effect was substantial over 7 days. Snowfall, snow depth, and wind advisories had effects lasting multiple days, presumably because of road conditions, power outages, or other infrastructure damage. Remigio et al. recommended further studies to determine whether peritoneal dialysis may offer benefits as a choice for patients living in areas with a higher frequency of extreme events. Considering that the consequences of multiple missed dialysis treatments can be horrific, involving medical complications or death, the study has predictive value for kidney patients and providers nationwide. The study also has strategic value for emergency managers and public officials because their decisions immediately before, during, and after a weather or other unplanned event can be either helpful or injurious to vulnerable people. They are also the decision makers with the authority to elevate awareness of kidney patients, and the need for dialysis treatment continuity, across emergency plans and tabletop exercises.

Beyond our shared New England roots, we have professional experiences in emergency operations through our respective past roles in federal and state governments and the military. After the terror attacks of September 11, 2001, we worked together to secure the bipartisan Congressional authorization and standup of the US Department of Homeland Security in preparation for future unplanned events, both natural and unnatural. We understand the data, resources, and relationships necessary, at every level, for emergency response, recovery, and rebuilding decisions. Of the many lessons we have learned, the most important one is to never take for granted that emergency managers and public officials closest to an impact zone possess the knowledge and bandwidth necessary to prioritize the needs of medically complex patients or their life-saving treatments. Their jobs are made easier, and their options are far better informed, when relevant information is offered proactively. The tragic death of a dialysis patient during recent record snowfalls in the California mountain town of Big Bear Lake City is a poignant reminder that knowledge gaps and inclement weather can be deadly anywhere in America. According to the Los Angeles Times, in the storm's aftermath, medical transportation was not allowed to pick up the patient for their scheduled treatment, which had fatal consequences.²

Medical societies, dialysis providers, and researchers have worked diligently to increase the kidney community's understanding about inclement weather, unplanned events, and consequences. In 2023, the International Society of Nephrology adopted this as a theme for World Kidney Day and for a World Kidney Congress special session. As former federal officials and advocacy leaders for the American Association of Kidney Patients, we encourage readers to broaden the audience by flagging this article for their local emergency managers and public officials to help them protect kidney patients and prepare for the worst.

Disclosures

P.T. Conway reports honoraria from Baxter and the Novartis/Global Transplant Patient-Reported Outcomes Patient Advisory Committee and Rare Kidney Disease Community Council. P.T. Conway reports leadership/advisory roles as the cochair of the American Association of Kidney Patients/George Washington University School of Medicine and Health Sciences Global Summit on Kidney Disease Innovations; as Chair of the Commonwealth of Virginia Renal Disease Council; as the Chair of Policy and Global Affairs and past president of the American Association of Kidney Patients; on the Nephrology Specialty Board of the American Board of Internal Medicine; for the Centers for Disease Control and Prevent Health Infections Control Practices Advisory Committee; as a Patient Voice Editor of CJASN; as cochair of the Centers for Medicare and Medicaid Dialysis 5 Star Technical Evaluation Panel; for the Congressionally Directed Medical Research Program of the Department of Defense; for the Food and Drug Administration Cardiovascular Devices Advisory Committee; for the Food and Drug Administration Medical Devices Advisory Committee; as the chair of the Patient Engagement Advisory Committee of the Food and Drug Administration; for the Kidney Health Initiative; on the Observational Study Monitoring Board of the Kidney Precision Medicine Project, National Institutes of Health (NIH)/National Institute of Diabetes and Digestive and Kidney Diseases; on the Contract Management Board of the Renal Data System; on the Advisory Board of the University of Pittsburgh/NIH Acute Kidney Injury-Caring For Outpatients study; and for the World Health Organization Lived Experience Research. E.V. Hickey reports advisory or leadership roles as President, Chair, Veterans Health Initiative of the American Association of Kidney Patients (AAKP); Patient Advisory Board, Intensity of Statin Therapy in Veterans with CKD Study, Veterans Administration Pittsburgh Healthcare System; Reviewer, US Department of Defense Congressionally Medical Research Program; and Member, Project Advisory Board, The Kidney Project; and Kidney stakeholder, US Food and Drug Administration Medical Device User Fee Amendment V Reauthorization Planning Team.

Funding

None.

Author Contributions

Conceptualization: Paul T. Conway, Edward V. Hickey.

Writing – original draft: Paul T. Conway.

Writing – review & editing: Edward V. Hickey.